Current through Register Vol. 41, No. 3, September 23, 2024
A. Home health services that meet the
standards prescribed for participation under Title XVIII, will be
supplied.
B. Home health services
shall be provided by a home health agency that is (i) licensed by the Virginia
Department of Health, (ii) certified by the Virginia Department of Health under
provisions of Title XVIII (Medicare) or Title XIX (Medicaid) of the Social
Security Act, or (iii) accredited by any organization recognized by the Centers
for Medicare and Medicaid Services (CMS) for purposes of Medicare
certification. Services shall be provided on a part-time or intermittent basis
to a recipient in any setting in which normal life activities take place. Home
health services shall not be furnished to individuals residing in a hospital,
nursing facility, intermediate care facility for individuals with intellectual
disabilities, or any setting in which payment is or could be made under
Medicaid for inpatient services that include room and board. Home health
services must be ordered or prescribed by a physician, nurse practitioner (NP),
clinical nurse specialist (CNS), or physician assistant (PA) and must be part
of a written plan of care that the practitioner shall review at least every 60
days.
C. Covered services. Any one
of the following services may be offered as the sole home health service and
shall not be contingent upon the provision of another service.
1. Nursing services;
2. Home health aide services;
3. Physical therapy services;
4. Occupational therapy services;
or
5. Speech-language pathology
services.
D. General
conditions. The following general conditions apply to skilled nursing, home
health aide, physical therapy, occupational therapy, and speech-language
pathology services provided by home health agencies.
1. The patient must be under the care of a
physician, NP, CNS, or PA who is legally authorized to practice and who is
acting within the scope of the practitioner's license. The practitioner may
serve the patient in an independent office, be on the staff of the home health
agency, or be a practitioner working under an arrangement with the institution
that is the patient's residence or, if the agency is hospital-based, be a
practitioner on the hospital or agency staff.
2. No payment shall be made for home health
services unless a face-to-face encounter has been performed by an approved
practitioner, as outlined in this subsection, with the Medicaid individual
within the 90 days before the start of the services or within the 30 days after
the start of the services. The face-to-face encounter shall be related to the
primary reason the Medicaid individual requires home health services.
a. The face-to-face encounter shall be
conducted by one of the following :
(1) A
physician licensed to practice medicine;
(2) A nurse practitioner or clinical nurse
specialist within the scope of practice under state law and working in
collaboration with the physician who orders the Medicaid individual's
services;
(3) A certified nurse
midwife within the scope of practice under state law;
(4) A physician assistant within the scope of
practice under state law and working under the supervision of the physician who
orders the Medicaid individual's services; or
(5) For Medicaid individuals admitted to home
health immediately after an acute or post-acute stay, the attending acute or
post-acute physician.
b.
The practitioner performing the face-to-face encounter shall document the
clinical findings of the encounter in the Medicaid individual's record and
communicate the clinical findings of the encounter to the ordering
physician.
c. Face-to-face
encounters may occur through telehealth, which shall not include by phone or
email.
3. When a patient
is admitted to home health services a start-of-care comprehensive assessment
must be completed no later than five calendar days after the start of care
date.
4. Services shall be
furnished under a written plan of care and must be established and periodically
reviewed by a physician, NP, CNS, or PA. The requested services or items must
be necessary to carry out the plan of care and must be related to the patient's
condition. The initial plan of care (certification) must be reviewed by a
physician, NP, CNS, or PA. The practitioner must sign the initial certification
before the home health agency may bill DMAS.
5. A physician, NP, CNS, or PA shall review
and recertify the plan of care every 60 days. A recertification shall be
performed within the last five days of each current 60-day certification
period, (i.e., between and including days 56 through 60). The recertification
statement must indicate the continuing need for services and should estimate
how long home health services will be needed. The physician, NP, CNS, or PA
must sign the recertification before the home health agency may bill
DMAS.
6. The physician, NP, CNS, or
PA orders for therapy services shall include the specific procedures and
modalities to be used, identify the specific discipline to carry out the plan
of care, and indicate the frequency and duration for services.
7. A written statement by a physician, NP,
CNS, or PA located in the medical record must certify that:
a. The patient needs licensed nursing care,
home health aide services, physical or occupational therapy, or speech-language
pathology services;
b. A plan for
furnishing such services to the individual has been established and is
periodically reviewed by a physician, NP, CNS, or PA; and
c. These services were furnished while the
individual was under the care of a physician, NP, CNS, or PA.
8. The plan of care shall contain
at least the following information:
a.
Diagnosis and prognosis;
b.
Functional limitations;
c. Orders
for nursing or other therapeutic services;
d. Orders for home health aide services, when
applicable;
e. Orders for
medications and treatments, when applicable;
f. Orders for special dietary or nutritional
needs, when applicable; and
g.
Orders for medical tests, when applicable, including laboratory tests and
x-rays.
E.
Utilization review shall be performed by DMAS to determine if services are
appropriately provided and to ensure that the services provided to Medicaid
recipients are medically necessary and appropriate. Such post payment review
audits may be unannounced. Services not specifically documented in patients'
medical records as having been rendered shall be deemed not to have been
rendered and no reimbursement shall be provided.
F. All services furnished by a home health
agency, whether provided directly by the agency or under arrangements with
others, must be performed by appropriately qualified personnel. The following
criteria shall apply to the provision of home health services:
1. Nursing services. Nursing services must be
provided by a registered nurse or by a licensed practical nurse under the
supervision of a graduate of an approved school of professional nursing and who
is licensed as a registered nurse.
2. Home health aide services. Home health
aides must meet the qualifications specified for home health aides by
42 CFR
484.80. Home health aide services may include
assisting with personal hygiene, meal preparation and feeding, walking, and
taking and recording blood pressure, pulse, and respiration. Home health aide
services must be provided under the general supervision of a registered nurse.
A recipient may not receive duplicative home health aide and personal care aide
services.
3. Rehabilitation
services. Services shall be specific and provide effective treatment for
patients' conditions in accordance with accepted standards of medical practice.
The amount, frequency, and duration of the services shall be reasonable.
Rehabilitative services shall be provided with the expectation, based on the
assessment made by a physician, NP, CNS, or PA of patients' rehabilitation
potential, that the condition of patients will improve significantly in a
reasonable and generally predictable period of time or shall be necessary to
the establishment of a safe and effective maintenance program required in
connection with the specific diagnosis.
a.
Physical therapy services shall be directly and specifically related to an
active written plan of care approved by a physician, NP, CNS, or PA after any
needed consultation with a physical therapist licensed by the Board of Physical
Therapy. The services shall be of a level of complexity and sophistication, or
the condition of the patient shall be of a nature that the services can only be
performed by a physical therapist licensed by the Board of Physical Therapy, or
a physical therapy assistant who is licensed by the Board of Physical Therapy
and is under the direct supervision of a physical therapist licensed by the
Board of Physical Therapy. When physical therapy services are provided by a
qualified physical therapy assistant, such services shall be provided under the
supervision of a qualified physical therapist who makes an onsite supervisory
visit at least once every 30 days. This supervisory visit shall not be
reimbursable.
b. Occupational
therapy services shall be directly and specifically related to an active
written plan of care approved by a physician, NP, CNS, or PA after any needed
consultation with an occupational therapist registered and licensed by the
National Board for Certification in Occupational Therapy and licensed by the
Virginia Board of Medicine. The services shall be of a level of complexity and
sophistication, or the condition of the patient shall be of a nature that the
services can only be performed by an occupational therapist registered and
licensed by the National Board for Certification in Occupational Therapy and
licensed by the Virginia Board of Medicine, or an occupational therapy
assistant who is certified by the National Board for Certification in
Occupational Therapy under the direct supervision of an occupational therapist
as defined in this subdivision. When occupational therapy services are provided
by a qualified occupational therapy assistant, such services shall be provided
under the supervision of a qualified occupational therapist, as defined in this
subdivision, who makes an onsite supervisory visit at least once every 30 days.
This supervisory visit shall not be reimbursable.
c. Speech-language pathology services shall
be directly and specifically related to an active written plan of care approved
by a physician, NP, CNS, or PA after any needed consultation with a
speech-language pathologist licensed by the Virginia Department of Health
Professions, Virginia Board of Audiology and Speech-Language Pathology. The
services shall be of a level of complexity and sophistication, or the condition
of the patient shall be of a nature that the services can only be performed by
a speech-language pathologist licensed by the Virginia Board of Audiology and
Speech-Language Pathology.
4. A visit shall be defined as the duration
of time that a nurse, home health aide, or rehabilitation therapist is with a
client to provide services prescribed by a physician, NP, CNS, or PA and that
are covered home health services. Visits shall not be defined in measurements
or increments of time.
Statutory Authority: §
32.1-325
of the Code of Virginia; Title XIX of the Social Security Act (
42 USC §
1396 et
seq.).
